Physiotherapy of Tension-Type Headaches

Rigmor Jensen

Julie Mills Roth

Physiotherapy is often used in the treatment of tension-type headache (TTH) despite limited scientific evidence demonstrating efficacy. In the field of preventive treatments for headache, the interventions studied were confined to pharmacologic and cognitive-behavioral therapies and mostly to the study of migraine. Only a few studies have assessed the effectiveness of traditional physiotherapy in properly classified TTH patients (13,40) as most have been conducted in mixed, not properly classified headache groups (20,32,35) or in a cervicogenic headache population (12).

Furthermore, most prior studies examining physiotherapy interventions for headache have consisted of case reports or uncontrolled or comparative designs. In TTH as well as in other pain disorders, it is extremely important to consider the placebo effect. Future treatment studies should therefore strive to utilize a randomized and controlled design.

The underlying rationale for physiotherapy, the applied methods, and the available research results will be discussed in the following sections.

In the field of pain management, physiotherapy as a discipline focuses primarily on the assessment and treatment of biomechanical dysfunction in an attempt to mediate or alleviate pain due to stress or strain on musculoskeletal structures. This approach works very well when treating headache associated with biomechanical dysfunction of the cervical spine (28,31,39). However, in the case of TTH, the approach differs. While the cause of TTH is still being debated, it is the current view that this disorder, especially the chronic form, is largely centrally mediated, as opposed to a primary disorder of the musculoskeletal system (4,6,9). Therefore, physiotherapy approaches to TTH focus more on mediating chronic adverse input into the central nervous system (CNS). For example, there is evidence that ongoing input to the CNS from muscular tension may in part be responsible for the evolution from episodic TTH (ETTH) to chronic TTH (CTTH) (see also Chapter 78), and physiotherapy may play a role in preventing this conversion (6,9,22). Thus, the physiotherapist must include a thorough evaluation of the musculoskeletal system in the TTH patient to rule out musculoskeletal factors that may be contributing to this centrally mediated disorder. This is especially true given the frequent coexistence of several headache diagnoses (43).

PRETREATMENT ASSESSMENT

The patient history is designed to elucidate any factors that may suggest musculoskeletal triggers for pain, as well as any strategies the patient may have already adopted for reducing his or her pain. The physical examination expounds on these findings, confirming or ruling out discrete musculoskeletal dysfunction such as joint hypomobility or irritability or myofascial trigger points (TrPs). It also helps to confirm the generalized pericranial tenderness found in TTH (4,9,28,35,39) (Table 82-1).

Careful palpation can differentiate the generalized tenderness of pericranial muscles found in TTH from the referred pain patterns found in myofascial TrPs. Increased tenderness of pericranial muscles revealed by manual palpation is one of the most consistent abnormal findings in patients with TTH (8,23, 24, 25, 26, 27), and to get a more precise quantification of tenderness a palpometer can be used (7). With a palpometer the investigator can perform palpation with the usual small finger movements and yet keep control over the palpation pressure (7). While this increased sensitivity of the pericranial muscles may represent some centrally mediated sensitization of the tissues, myofascial TrPs more likely represent a peripheral component. Myofascial TrPs are tender nodules embedded in taut bands of muscle tissue that, when palpated, refer pain to a distant site. There is increasing evidence that a TrP represents a
dysfunctional motor endplate, with increased spontaneous electrical activity (36, 37, 38), whereas others have been unable to demonstrate this finding (Couppe et al., personal communication).

TABLE 82-1 Key Points of Patient History

A.	What brings on the pain/what makes it worse? (helps to determine biomechanical problems or stress-mediated exacerbations)
B.	What can you do to make it better? (may give ideas about treatment)
C.	Was the onset related to a specific event (traumatic or otherwise)?
D.	What kind of activities do you do during the day?
E.	What are your work duties?
Patient Examination
A.	Inspection of the patient and observation of the facial expression (wrinkling the forehead, narrowing the eyes, or clenching the jaw)
B.	Observation of how the patient stands, sits, and moves, especially the positioning of the head and shoulders
C.	Muscle palpation to determine presence of trigger points, increased muscle tone, or generalized tenderness in the pericranial muscles
D.	Active and passive mobility testing to look for biomechanical dysfunction involving the cervical spine or related musculature
E.	Evaluation of the masticatory system

An active TrP is one that, when palpated, reproduces all or some of a patient’s primary pain complaint. TrPs so defined are rarely noted in the literature concerning TTH. Thus, their presence or absence needs to be determined by the individual evaluator, as treatment strategies will differ depending on the results of the TrP examination. Objective and reliable methods for identifying TrPs are not well established (7,23), but there is some evidence of interrater reliability in examiners with experience and training (16,17). In a very recent blinded and controlled study, active TrPs were identified in 85% of the CTTH patients in contrast to only 30% of healthy controls (Couppe et al, submitted 2004), suggesting a significant presence in this disorder.

Active and passive neck mobility should also be screened, as restrictions can point to shortened muscles, increased muscle tone, or joint dysfunction and hypomobility.

Increased tone of cervical muscles (due to poor posture or anxiety) may promote cranial muscle tension because of functional continuity between shoulder, neck, and scalp musculature (13). Both the Cybex equipment and the goniometer measure neck mobility in degrees and are simple and reliable (44).

The masticatory system must also be examined. Bruxism and other muscular hyperactivity of pericranial and masticatory muscles have been considered as causes of tenderness and pain (26). Jaw clenching is often combined with a protrusive posture of the head that gives rise to increased tone in the neck muscles. Several studies have reported an association between TTH and dysfunction of the masticatory system but the cause-effect relation is unclear (2,3,34).

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